Hospital in Cienfuegos, Cuba. AP Photo/Franklin Reyes. All rights reserved.
In recent decades, progress in Latin American societies has been shifting the focus of public debate from the fight against authoritarian regimes, the lack of freedom and crises related to extreme poverty, exploitation and underdevelopment, towards the consolidation of democratic transitions, the conquest and defense of social and civil rights, and the construction of a developing welfare state, a typical feature of advanced societies which is here an established aspirational goal. Although structural weaknesses in the region are still plentiful, the discussion on healthcare systems, their universalization and accessibility has been gaining ground among the political priorities of multilateral agencies and national governments, local political actors, human and civil rights activists, and different actors from organized civil society and the economic and business world.
Even though Latin America carries the weight of some constitutive problems that hinder the development of its societies, in the last decade some progress has been reported which certainly needs consolidating and strengthening, but leads us to believe that the debate on health in the region, which the Barcelona Institute of Global Health (ISGlobal) and DemocraciaAbierta are proposing through a series of forthcoming articles, is particularly relevant at this point in time and may hopefully have some impact on the debate on the development of a healthcare ecosystem throughout the continent.
Three areas of action
We propose to approach a series of reflections in three major areas: the issue of inequality and its impact on health systems, the debate on universal coverage, and issues related to access and quality of healthcare services, including those related to indigenous peoples, gender equality, and the vulnerability of excluded people in rural areas and large urban suburbs.
The gender question, and the access to sexual and reproductive health in a region where violence, sexism and historical inequality are inbred in the cultural context, deserve special attention. Linked to all of the above, the problems associated with epidemics (such as the recent case of Zika virus) and infectious diseases have also a continental dimension.
Ultimately, we seek to contribute elements of analysis and reflection to an informed and plural but not necessarily expert audience, to help answer the question of what future for healthcare in Latin America and the Caribbean do the actors and the populations want, as the answer to this question will also depend on the quality of their democratic systems of government and the governance of the common good.
Even though some goals in healthcare have improved, Latin America remains the most unequal region in the world: in 2014, 71% of the wealth of the region belonged to the richest 10% of the population. Inequities exist not only among Latin American countries, but also within each of them. As underlined by several regional analyses, particularly those carried out by the Economic Commission for Latin America and the Caribbean (ECLAC), inequality in healthcare is due not only to the lack of socio-cultural and geographical accessibility, but also to income inequalities which generate living conditions that are inadequate for anticipating and meeting the healthcare needs of the population.
The poor are more likely than the rich to develop health problems and are less able to use basic services such as preventive care, which is key to early detection of diseases and appropriate intervention. A recent study by the World Bank conducted in 9 countries in the region indicates that, while the current rate of impoverishment is relatively low and is gradually declining due to public spending on health protection systems, two to four million people remain below the poverty line once their spending on healthcare is discounted.
At the same time, the changing demographic and epidemiological profile of the region, particularly the aging population, is shifting the burden of morbidity towards chronic diseases, which have increased in all population groups. This means greater and more widespread demand for healthcare services and an expected rapid increase of the budget burden.
As a demographic dependency factor, the aging population is a crucial element to consider for the dynamics of the protection systems and the welfare regimes. In the poorest families, care for dependents is something that can hardly be met by the market and is largely provided by women in family environments, which entails gender effects for the individual development and labour-market integration of women.
In too many places in Latin America and the Caribbean access to quality healthcare services is restricted to high-income earners. In addition, the commodification of these services makes them more expensive and drives them away from poverty and vulnerability areas. Thus a vicious cycle is put into motion that affects the quality of life and the process to guarantee human, political and social rights for millions of people.
Inequality affects both the social determinants that influence health and access to healthcare. Healthcare inequality, in turn, causes more poverty, and diverts communities from the path towards the progressive realization of a basic right.
Universal Health Coverage
Universal Health Coverage implies that all individuals and communities, without discrimination, have access to comprehensive, quality healthcare according to their needs, and to quality drugs that are safe, effective and affordable, and that the use of these services does not result in financial difficulties for their users, particularly the vulnerable groups. Reference to this is to be found in Estrategia para la Cobertura Universal en Salud (PAHO/WHO).
After years of debate and work on healthcare approach in the national and international development agendas, last September the United Nations General Assembly approved the Agenda 2030, broken down in 17 sustainable development goals (SDGs), among them SDG 3 which aims to achieve Universal Health Coverage and provide drugs and vaccines that are safe, effective and affordable to all.
Several paths have been tried in Latin America and the Caribbean, with varying degrees of success, in relation to universal coverage. Some countries have experienced similar results to the Organization for Economic Cooperation and Development (OECD) countries, despite the fact that they launched their programs and policies to improve population coverage, access to healthcare services and financial protection much later. However, there are still millions of people in the region who lack access to comprehensive healthcare services and thus cannot lead healthy lives and prevent disease, or receive healthcare service assistance when sick, including palliative care in the terminal phase of an illness.
After nearly a quarter of a century's experience with reforms to further the Universal Health Coverage in Latin America and the Caribbean, it is particularly relevant to analyse not only the concept and its composing elements from a Latin American perspective, but also the ways to protect them against regressive policies that threaten, ultimately, the fulfilment of the Right to Health.
Service (access and quality)
Deficient quality in healthcare shows itself in many ways: limited access to healthcare services, ineffective and inefficient services, medical complaints, high costs, dissatisfaction on the part of both users and health professionals, low credibility of the healthcare institutions and the health sector as a whole. Worse still, as PAHO notes, poor quality in the provision of healthcare services comes to mean the loss of human lives.
So, this is not a problem that has to do only with financing, and other issues need to be addressed, for example the management capacity of the healthcare systems to provide quality services when, in many countries in the region, their control and governance is not in state hands.
Some of the questions we will be discussing in the series are: Is progress being made in Latin America towards healthcare models centred on people, especially the most vulnerable, and based on their needs? While providing a range of guaranteed benefits, is due attention being paid to the quality of the healthcare services? How is the challenge of accessing diagnosis and treatment of the "poverty diseases" to be addressed?
In the most unequal region in the world, progressively consolidated democratic aspirations cannot be met without comprehensively addressing the causes of the precarious health of the population and expanding further public health policies. Electoral democracy is not enough if it does not guarantee services linked to fundamental human rights such as access to health services.
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